Next stop: the top. In the meantime, Cyndie Miculan, MSN, RN, is honing her skills and thoughts on nursing, leadership and education as a relatively new nurse manager in Greenville, N.C.

Miculan, a manager for a little more than two years, began July 1 as head of the family medicine floor at Pitt County Memorial Hospital. It's the next step in a career that will have taken her from a later-in-life diploma nurse to earning bachelor's and master's degrees and now-she hopes-to health care administration.

A desire to understand the business of nursing spurred her to an advanced degree and the mastery of once-daunting concepts, such as the origin and application of statistics, for instance, in the allocation of resources. Miculan said she's found that management is filled with the nuts and bolts of departmental budgets, hiring, scheduling and performance evaluations, but the most rewarding part is mentoring and guiding.

"A lot [of the] time as managers, we're just a support person," she said. That's how she views herself-as a leader.

Miculan formally teaches a basic life-support course. Informally, through mentoring, she teaches her RNs self-preservation as they care for patients with chronic conditions: sickle cell anemia, the effects of stroke, amputations and nursing home residents on the decline.

Nurses on the family medicine floor are young enough that they have yet to experience burnout, Miculan said, and with mentoring she would like to help them avoid it forever.

The burnout she occasionally witnessed as a staff nurse in Akron, Ohio, "came from people who wanted to do it all themselves, who had the typical type A personality: We want it done now, we want it done right and we want to do it," Miculan said. While those are the utterances of good nurses, "it's also a recipe for self-defeat," she said. "It's not necessary that they do everything by 9 o'clock in the morning. It's not necessary that they do everything today. And it's not necessary that they themselves have to do it all. That's a hard thing for nurses."

Miculan said that accepting the slow pace of change, whether it's staff learning to delegate and prioritize or enhancing the delivery-of-care system, is among the more difficult things for her to do as a manager.

"I was thinking I could walk in and say, 'I'm going to do something' and actually do it. But in the real world, it needs to go through a lot of committees and decision-makers," she said. For example, "to tweak that care delivery system, which could mean the mix of professionals and nursing assistants or actually how the jobs are divided out, it goes through a lot of channels before it can be changed. It's not enough to walk in and say, 'OK, we're going to try this.' I wasn't prepared for the time lag."

Nor was she prepared for the expense of a nursing education that, for lack of money, she put off until she had married, run a bakery for 20 years and reared two children. "Between my student loans and the student loans of my children, I don't know that I'll ever be able to retire," Miculan, 48, said. "But advanced education is an important asset."

She said she's "a little uncomfortable" that North Carolina does not require continuing education of RNs.

Ohio, where she began her nursing career in 1993, is one of 29 states and the District of Columbia that requires continuing education credits or a minimum number of hours of practice for license renewal. The others are Alabama, Alaska, Arkansas, California, Delaware, Florida, Iowa, Kansas, Kentucky, Louisiana, Massachusetts, Michigan, Minnesota, Nebraska, Nevada, New Hampshire, New Mexico, New York, North Dakota, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, West Virginia and Wyoming.

Of the states without a continuing education component for RNs, seven do require it for re-licensure of advanced practice nurses: Georgia, Hawaii, Idaho, Maine, Mississippi, New Jersey and Washington.

"I think nurses, as a professional obligation, need to continue their education. I feel they need refreshers every year and there should be some way of measuring it," Miculan said.

Besides asking RNs to encourage family and friends into nursing, where there are a thousand directions to go, all starting with the same basic skills, the importance of education is Miculan's pet message. "Go back to school," she said. "Go for it."

Contact Phil McPeck at getpjm@aol.com.